How Can I Get Medicare Disability for Fibromyalgia?
guest post by Danielle K. Roberts
If you’re under 65, you’re not eligible for Medicare benefits unless you have a qualifying disability under Social Security Administration (SSA) guidelines.
Unfortunately for fibromyalgia sufferers, getting a disability determination on that basis can be difficult.
That’s not to say it’s impossible, however. The SSA recognized the potentially unfair obstacles for people with fibromyalgia and issued new guidelines for fibromyalgia disability claims in 2012.
Getting access to Medicare benefits due to disability for fibromyalgia isn’t easy, but it can be done. Here’s what you should know so you have the best chance of getting approved.
Understanding fibromyalgia and “medically determinable impairment”
The first hurdle in getting a disability claim approved is proving a “medically determinable impairment,” or MDI, with Social Security.
The SSA defines an MDI like this: “an impairment that results from anatomical, physiological, or psychological abnormalities that can be shown by medically acceptable clinical and laboratory diagnostic techniques.”
In plain language, it means that your impairment, or disability, must be backed up with objective medical tests and evidence.
It’s not enough to just have subjective statements that you have a disease or condition—the SSA needs proof.
That’s where things get difficult for people with fibromyalgia.
Unlike other conditions such as rheumatoid arthritis or disc disease which can be seen on x-rays and other imaging studies or lab work, there’s no definitive test that proves fibromyalgia.
Diagnosis usually depends on self-reported symptoms of pain, dizziness, “fibro fog,” and other classic signs of fibromyalgia.
Related: How is fibromyalgia diagnosed?
The 2012 ruling attempted to clarify when disability examiners could consider fibromyalgia as a medically determinable impairment.
The rule is based on criteria developed by the American College of Rheumatology to diagnose fibromyalgia.
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To get an MDI determination for fibromyalgia, you need a documented medical history of widespread chronic pain and lab and diagnostic tests that prove the symptoms aren’t related to another disease or condition such as lupus or multiple sclerosis.
From there, one of the following must also be documented before you qualify for a fibromyalgia MDI:
- Pain in at least 11 of 18 different sites in the body, occurring on both sides, with some both above and below the waist. You can see the pain-points diagram in the SSA fibromyalgia ruling.
- Multiple episodes of six or more fibromyalgia-related symptoms, such as poor sleep, memory problems, bowel symptoms, muscle weakness, seizures, and depression.
The disability examiner will carefully review your medical records for evidence that all the above conditions exist before granting a fibromyalgia MDI.
You’ll need to provide at least 12 months of medical records documenting your symptoms and treatment; in some cases, you may be asked for older records, as well.
A fibromyalgia diagnosis from a specialist, such as a rheumatologist, carries more weight with disability examiners than a similar diagnosis from a general practitioner.
If your doctor believes you have fibromyalgia, ask for a referral to a specialist to confirm the diagnosis.
I have a fibromyalgia MDI determination, now what?
The next step involves determining whether your fibromyalgia is severe enough that it prevents you from being able to work at any type of job.
At this stage, your disability examiner will complete a Residual Functional Capacity, or RFC, assessment. The RFC documents both the activities you can do, and those you cannot, due to limitations from fibromyalgia.
The RFC looks at both exertional and non-exertional tasks as well as mental tasks to make a disability determination. Exertional tasks include things such as walking, standing, lifting, pushing, and pulling.
Non-exertional tasks include things such as stooping, using your hands to write and handle objects, speaking, hearing, seeing, and the ability to tolerate conditions of heat or cold.
Mental tasks deal with intangibles such as your ability to handle stress, to remember and carry out instructions, make reasonable judgments, react appropriately with co-workers and customers, and maintain a consistent work schedule.
Once the RFC is completed, the disability examiner will compare your limitations with the types of jobs available. If there are no suitable jobs for someone with your RFC, you’ll get a disability determination.
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The more complete and detailed your records are, the better your chances of getting a disability determination.
Disability experts recommend keeping a journal of your symptoms. Make notes of your physical and emotional condition each day, any persistent or unusual symptoms, and what you’re doing to manage them.
The journal will help your doctor find the right treatment as well as provide a thorough record for the SSA examiner.
Ask your doctor to complete an assessment of your functional capacity, especially regarding limitations to walking, sitting, standing, bending, lifting, and carrying over the course of an eight-hour work-day.
Ask him to provide an opinion of how any mental limitations from fibromyalgia might affect your ability to keep good attendance at work and handle typical stresses on the job.
If you worked in the past but left work because of fibromyalgia, statements from co-workers about specific limitations they observed may also be helpful. For example, if you needed to take extra breaks during the day because of fibromyalgia-related pain or fatigue, that might support your disability claim.
The disability approval process typically takes between three and five months. You can download the disability starter kit from the SSA; it includes a checklist for your disability interview and a worksheet to help you gather the information you’ll need for your application.
Keep in mind, you can appeal any denials or decisions at any stage of the process—including your benefit amount if you are awarded disability. You can find more information about the appeals process from the SSA website.
Getting Medicare after a disability finding
In most cases, you’ll be automatically enrolled in Medicare after your 24th month of disability payments from Social Security. Your coverage starts on the first day of the 25th month of collecting disability.
Danielle K Roberts is a Medicare insurance expert. You can learn more about her and her team at Boomer Benefits
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- The importance of getting your medical records